Every finding on record at Shores Hospice LLC

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by interview and observation. In 1 of 1 (100%) home visits made revealed that the agency did not ensure that standards of practice to prevent the transmission of infections and communicable disease such as hand hygiene and safe handling of equipment were followed during the home visit. This is a Continued Required Action HOME VISIT 1: During a home visit on 03/31/2025 with the RN in an ALF the RN changed her gloves two times without sanitizing her hands in between changes while doing the patient assessment. She used a stethoscope, thermometer, and pulse oximeter to perform vital signs on the patient and returned the equipment back to nursing bag without cleaning the equipment. There were no designated areas in the bag for clean and dirty equipment. During an interview with the clinician after her visit she stated that she usually cleans her equipment when she gets back to her car and then puts it back in her bag. This is a continued Finding

It is required that each patient’s individualized written plan of care: Reflects patient and family goals; and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure the plans of care were updated to reflect patient and family goals and interventions based on problems identified in the initial comprehensive and updated comprehensive assessments. Clinical Record 7: The patient elected hospice care on 07/14/2022 with a primary diagnosis of Chronic Diastolic (congestive) Heart Failure. An Interdisciplinary group meeting and plan of care update dated 09/13/2023 included the new onset of wheezing and shortness of breath that was documented in the skilled nursing comprehensive assessment narrative notes. Additional documentation present in the record, regarding the patient's change in condition, included physician orders dated 09/12/2023 for "Azithromycin 5-day dose pack, 250 mg oral tab", and 09/19/2023, for "Cipro 500mg oral tab q12 x 7days". Review of the patient's plan of care revealed it was not updated to include goals and interventions related to the patient's suspected acute respiratory infection. Clinical Record 12: The patient elected hospice care on 08/25/2023 with a primary diagnosis of Parkinson's Disease. The physician's certification of terminal illness and the initial comprehensive nursing assessment both stated that the patient had a suprapubic catheter in place. The plan of care dated 08/25/2023 did not include any documented orders related to the care and management of the suprapubic catheter, and related goals and interventions. The record showed evidence that hospice staff were assessing the functioning of the suprapubic catheter during visits but had not provided direct care as the family had been caring for the catheter long before electing hospice care. During joint clinical record review and interview on 11/07/2023, the Administrator/Director of Patient Care Services reviewed and agreed that the identified plans of care were missing documentation of goals and planned interventions based on the problems identified.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the organization did not ensure that the individualized written plan of care (POC) included measurable outcomes anticipated from implementing and coordinating the POC. Clinical Record 3: The patient elected hospice care on 9/04/2023. The patient's individualized plan of care (POC) dated 9/04/2023 included documentation of a Medical Social Work (MSW) goal which stated, "Patient will maintain optimal coping through hospice care". The goal statement did not include a description of how the achievement of "optimal coping" by the patient would be measured. Clinical Record 6: The patient elected hospice care on 11/18/2022. The patient's individualized POC dated 11/18/2022 included documentation of an MSW goal which stated, "Patient will maintain optimal coping through hospice care". The goal statement did not include a description of how the achievement of "optimal coping" by the patient would be measured. Clinical Record 14: The patient elected hospice care on 5/23/2023. The patient's individualized POC dated 5/23/2023 included a skilled nursing goal that stated, "Patient will maintain optimal level of functioning appropriate for stage of disease process". The goal statement did not include a description of how the achievement of "optimal coping" by the patient would be measured. During joint clinical record review and interview on 11/06/2023, the Administrator/Director of Patient Care Services reviewed and agreed that the identified POC goals were non-measurable.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. In 2 of 3 (67%) home visits it was observed that the agency did not ensure clinical staff completed hand hygiene as described in the organization's policy. The organizational policy, No. 7-009 (Revised April 2020), stated in part, "Hand decontamination using an alcohol-based hand rub should be performed... after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient... [and] after removing gloves." Home Visit 1: During a home visit on 11/06/2023, the staff member (Staff 1) was observed interacting with the patient and touching the patient's bed without sanitizing their hands before touching the patient. The staff member then exited the patient's room, walked to the nurse's station, and began using the facility's hospice chart without first sanitizing their hands. Home Visit 2: During a home visit on 11/07/2023, the staff member (Staff 2) was observed wearing gloves while taking the patient's temperature and oxygen saturation level and then removed the gloves and reached into their clinical bag without first sanitizing their hands. During the daily wrap-up conference with the Administrator/Director of Patient Care Services on 11/06/2023, the evidence was reviewed and agreed upon that the clinician (Staff 1) did not follow proper hand hygiene upon touching inanimate objects in patient's vicinity. Additionally, during the daily wrap-up conference with the Administrator/Director of Patient Care Services on 11/07/2023, the evidence was reviewed and agreed upon that the clinician (Staff 2) did not follow proper hand hygiene when using gloves.

It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 7 (14%) personnel records reviewed it was revealed that the organization did not ensure licensed professionals participated in hospice in-service training. The organizational policy, No. 1-028 (reviewed 4/2023), stated in part, "[Name] Hospice requires that each staff member and staff under arrangement complete a minimum of the following programs each year… These programs must include patient rights and responsibilities, standard precautions and infection control [etc.]." Personnel Record 10: The personnel record for this Hospice Medical Director, with a date of hire of 07/07/2020, did not include evidence of participation in the hospice sponsored in-service training related to patient rights and responsibilities, standard precautions, and infection control in 2021, 2022, and 2023, to date. Review of the Medical Director’s role and responsibilities revealed they provided direct care to patients and completed Face-to-Face visits when needed. During the daily wrap-up meeting on 11/7/2023 the Administrator/Director of Patient Care Services stated during interview that she was unaware the Medical Director was required to participate in annual in-services.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) applicable clinical records of patients who received hospice aide services it was revealed that the hospice did not ensure the plan of care (POC) was updated by the IDG/RN as frequently as the patient's condition required. Clinical Record 11: The patient elected hospice care on 01/25/2022 and was discharged for death on 12/25/2022. A skilled nursing comprehensive assessment on 12/20/2022 included a narrative that stated in part: "Patient unresponsive. Suspect eminence." The aide plan of care in effect on 12/20/22 assigned the aide to provide the patient with, "Hygiene: Shower", and there was no documented evidence that the aide plan was updated to assign the aide to complete a different type of bath. During joint clinical record review on 11/07/2023 the Administrator/Director of Patient Care Services (DPCS) stated, "She [the nurse] forgot to update the aide plan of care." During an Interdisciplinary Group (IDG) Meeting on 11/08/2023, the Administrator/DPCS provided education to the IDG regarding updating the POC as frequently as the patient's condition requires rather than waiting for the formal IDG meeting.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the organization did not ensure that the clinical record contained accurate documentation on hospice aide visit notes that described the care provided by the aide. Clinical Record 11: The patient elected hospice care on 01/25/2022 and was discharged for death on 12/25/2022. A skilled nursing comprehensive assessment dated 12/20/2022 included a narrative note that described the patient as bed bound and stated in part, "Patient unresponsive. Suspect eminence." Two hospice aide visits were completed on 12/20/2022 and 12/23/2022, which occurred after the nursing assessment that identified the change in the patient's condition. Documentation on the corresponding aide visit notes described the bath type provided to the patient by the aide as, "Hygiene: Shower -Done", which was the task that was assigned on the aide plan of care and was not revised by the registered nurse when the change in the patient's condition was assessed. An interview with the Administrator/Director of Patient Care Services on 11/7/2023, revealed that the patient was in fact bed bound during the aide visits on 12/20/2022 and 12/23/2022 and the hospice aide actually provided a bed bath for the patient but did not accurately document the bath type that was provided on the aide visit notes.